Contamination compulsions and obsessive-compulsive disorder during COVID-19

To the Editor

Handwashing and avoiding contact are encouraged to combat COVID-19, the largest global pandemic since 1918. People with obsessive-compulsive disorder (OCD) can have a disproportionate or irrational concern regarding their risk of, or responsibility for, infectious transmission and subsequently engage in excessive handwashing and significant avoidance of potential contaminants – exposure to such fears is core part of OCD treatment. It is therefore important to explore the effects of the pandemic on people with OCD in order to understand how best to assess and manage the condition (Kumar and Somani, 2020). We report our experience of the assessment and management of OCD in the early stages of COVID-19 in Australia with reference to recent international guidelines and other resources.

Responses of OCD to COVID-19 have varied. Some patients with OCD, including those with contamination fears, have had increased anxiety during the pandemic and this may have affected capacity to present to clinical facilities for care. Other people with OCD have reported feeling reassured that there are now strict guidelines about handwashing, and that they have felt validated regarding their usual excessive concerns about contamination, their excessive cleaning and their avoidance of potential contaminants. People with non-contamination OCD symptoms seem to be about as concerned than the general public. That is, the pandemic precautions of avoidance and handwashing may, in fact, have led to apparent reduced anxiety in some patients. In contrast, the same behaviours of avoidance and handwashing for those unaccustomed, that is without OCD, are more stressful. However, these early observations are bound by the context of Australia’s relatively low per capita mortality rates.

International clinical practice guidelines (Fineberg et al., 2020) contain six principles for OCD management during COVID-19: (1) the use of telehealth in context of resource availability; (2) diagnostic assessment for OCD symptoms relative to health anxiety and normative responses; (3) suicide risk assessment; (4) education about COVID-19 (e.g. health.gov.au); (5) assess media consumption and encourage reliable sources (e.g. nhs.uk/video/pages/how-to-wash-hands.aspx); and (6) for confirmed clinical OCD symptoms (a) pharmacotherapy as first-line treatment, (b) risk assessment of contamination-domain ‘exposure and response prevention’ (ERP) therapy and continuation of non-contamination ERP, (c) social/occupational adaptive practices and (d) and carer support.

Our early anecdotal evidence appears to suggest that COVID-19 has had an unexpected positive impact for the mental health of some, but not all, people with OCD. However, ongoing analysis is needed to assess the final impact (Banerjee, 2020). International organisations provide COVID-19-specific support resources for clinicians and consumers (iocdf.org/covid19/) that may be useful when assessing and treating people suffering from OCD.